Effective Team Communication and Emergency Cesarean Section Delays, Capstone Project Example

Abstract

The objective of this study is to examine effective team communication and emergency cesarean section delays with a focus on team communication and timely emergency cesarean section deliveries. It is reported that approximately “1.1% of babies who are born via cesarean “suffer injuries, such as skin laceration, abrasion, bruising, subconjunctival hemorrhage, cephalohematoma, clavicular fracture, facial nerve injury, brachial plexus injury, skull fracture, long bone fracture, and intracranial hemorrhage.” (Simpson, 2007) In fact, it is reported that babies “born less than 5 minutes after the incision time have a higher injury rate than babies born more than 5 minutes after the incision time.” (Simpson, 2007) This work examines the litearature on effective teamwork in labor and delivery in relation to the conduction of cesarean deliveries.

Effective Team Communication and Emergency Cesarean Section Delays

Introduction

The objective of this study is to examine effective team communication and emergency cesarean section delays with a focus on team communication and timely emergency cesarean section deliveries.It is reported that approximately 1.1% of babies who are born via cesarean “suffer injuries, such as skin laceration, abrasion, bruising, subconjunctival hemorrhage, cephalohematoma, clavicular fracture, facial nerve injury, brachial plexus injury, skull fracture, long bone fracture, and intracranial hemorrhage.” (Simpson, 2007) In fact, it is reported that babies “born less than 5 minutes after the incision time have a higher injury rate than babies born more than 5 minutes after the incision time.” (Simpson, 2007)

Teamwork and Communication

The work of Deering, et al (2011) entitled “Multidisciplinary Teamwork and Communication Training” reports the fact that in the perinatal hospital environment “every delivery, is, by necessity, a multidisciplinary event. It involves nursing, a delivering provider (obstetrician, family medicine, or midwife), often an anesthesia provider, and a pediatrician to take care of the baby after delivery should resuscitation be required. It is not unusual for patients to be in labor for many hours and be on the delivery ward across many different shifts, necessitating multiple handoffs between the providers and teams.” (Deering, et al, 2011)

It is reported that each of these ‘handoffs’ presents a new potential error. Deering et al (2011) additionally reports the fact that the science of team performance training “originated forms the attempts of commercial and military aviation to improve flight safety. Crew resource management (CRM) focuses on skills, such as communication, leadership, and decision making, of flight crews.” This program further gives encouragement for using all resources available including “equipment, procedures, and staff, to promote safety and enhance efficiency.” (Deering, et al, 2011) This program was first utilized at a NASA workshop in 1979 and resulted in the notation that “human error was the primary cause of mot aviation accidents, CRM has since been adapted for use in other high-risk industries.” (Deering, et al, 2011)

CRM &TeamSTEPPS

CRM is reported to have been first utilized in the healthcare field in the operating room of a University Hospital in 1994 in Basel, Switzerland. It is stated that in 2001, “… the IOM recommended that this type of training be used to increase patient safety and it is also advocated by the National Academies, the Agency for Healthcare Research and Quality and the Institute for Healthcare Improvement.” (Konschak and Sirois, nd) Konschak and Sirois (nd) report the use of CRM training programs in varied settings of healthcare which are stated to be inclusive of such as “…operating rooms, anesthesia departments, emergency departments, intensive care units and labor and delivery departments. Standard cockpit procedures such as communication protocols, checklists and team briefings are increasingly being used to improve patient care.” (Konschak and Sirois, nd)

According to Konschak and Sirois (nd) the in the British Medical Journal, the Journal of the American Medical Association and the Journal of Critical Care that “hospitals that adopt these measures have fewer malpractice suits and post-surgical infections as well as lower patient recovery times and higher employee satisfaction.” (Konschak and Sirois, nd) It is reported by Konschak and Sirois (nd) that there are “parallels between aviation and medicine that make CRM a potentially valuable tool.” The reasons stated are those as follows based on the fact that both the aviation and healthcare industry:

• Have a risk of adverse events that are the result of human error, especially failures in communication, leadership and decision-making;
• Depend on technological innovations;
• Require long periods of technical training;
• Rely on teams led by leaders with strong roles;
• Involve situations where personnel can spend hours performing mundane tasks and then be required to act swiftly under extreme stress;
• Encompass a work environment where human error poses a significant risk of serious adverse events; and
• Rely on personnel that suffer from critical performance impairment when exposed to excessive levels of stress, fatigue, or other adverse physiological factors. (Knoschak and Sirois, nd)

Deering et al (2011) report that health care is one primary field, which is characterized by a high-stakes environment “in which errors can lead to deleterious outcomes.” The healthcare field adopted human factors training for the purpose of improving the performance of those who provide health care. Furthermore, team strategies and tolls for enhancing performance and the safety of patients (TeamSTEPPS) is reported as having been “developed by the Department of Defense’s patient safety program in collaboration with the Agency for Healthcare Research and Quality to extend the military’s research on team performance to health care.” (Deering, et al, 2011)

TeamSTEPPS is reported as being characterized by “an essential set of interrelated knowledge, skills, and attitude competencies being identified this program includes “…leadership, mutual performance monitoring, mutual support, and communication. (Deering, et al, 2011) TeamSTEPPS has as its design the creation and sustaining of “a culture of safety by producing highly effective medical teams that optimize resources, increasing team awareness, resolve conflicts, and eliminate barriers to quality and safety.” (Deering, et al, 2011)

The five skills stated as being associated with CRM are those of:

(1) Inquiry;

(2) Listening;

(3) advocacy/assertion;

(4) Resolving conflict; and

(5) Closing the loop. (Konschak and Sirois, nd)

The development of standard operating procedures and checklists reduces the chance of steps that are critical being accidentally omitted. CRM is also inclusive of the education of team members on safety issues and limitations of human performance. In the field of healthcare, this would include team members being instructed about the individual’s potential for error and why it is that errors occur and what situation or situations are likely to increase the risk for errors to occur. Instructions are likely to include “practical strategies for dealing with human fallibility, such as how to stop errors before they cause harm or how to mitigate the effect of harm, as well as how to learn from errors that take place.” (Konschak and Sirois, nd)

CRM encourages error reporting since reporting of errors “serves as a mechanismtoensure that team members learn from their errors and take steps to prevent their recurrence.” (Konschak and Sirois, nd) Research demonstrates that CRM training improves multidisciplinary effectiveness in acute care and reported are the following successful implementations of CRM in the field of healthcare: (1) In Michigan, the infection rate in ICUs decreased by 66 percent within the first three months of a widespread initiative to use checklists. Michigan’s infection rates fell so low that its average ICU outperformed 99 percent of ICUs nationwide. In the first 18 months of the initiative, hospitals saved an estimated $175 million and more than 1500 lives; (2) A 19-item surgical safety checklist developed by the World Health Organization reduced the death rate within 30 days of surgery by 47 percent in a study that involved eight hospitals around the world. Major complications dropped from 11 percent to 7 percent. The checklist included items such as marking the body part to be operated on before giving the patient anesthesia; before making the first incision, making sure that everyone in the operating room knew one another and what their roles would be; and checking that all needles, sponges and instruments were accounted for after surgery. It is reported that “the clinical error rate went from 31 percent to 4.4 percent in a group of nine hospital Emergency Departments where formal teamwork structures and processes were implemented” and that following the implementation of a teamwork initiative to promote a culture of patient safety that the

“Adverse Outcome Index (the percentage of patients with one or more of 10 identified adverse events) improved 47 percent for high-risk prematurebirths, The clinical error rate went from 31% to 4.4% in 9 EmergencyDepartments that used formal teamwork structures. 14 percent for termdeliveries, and 16 percent overall from 2001 to 2004 at Beth IsraelDeaconess Medical Center. (Konschak and Sirois, nd)

The work of Alex, et al (2010) entitled “The Ongoing Challenges of Regional and General Anesthesia In Obstetrics” states that one of the primary challenges for the obstetric anesthetist is to be called upon to provide support for an immediate caesarean delivery, typically in the situation of impending maternal-fetal demise. The potential problems here are legion; the unprepared anesthetists may be compelled to administer general anesthesia unless less than ideal conditions to an unfasted patient.” (Alex, et al, 2010)

Alex et al (2010) additionally reports that some “stat cesarean sections may not be easily predicted and may present suddenly, such as a collapsed pregnant patient who requires a per-mortem caesarean delivery when time is of the greatest essence. In this respect, previous audits have revealed that the longest delay in the decision-to-delivery intervals is the time taken to transfer the patient to the operating theatre and the timely assembly of staff.” (Alex, et al, 2010) Alex, et al (2010) reports that the key to successful management of an emergency cesarean section is “communication and teamwork between the caregivers.”

Study Evaluation Effect of Teamwork Training on Adverse Outcomes and Process of Care in Labor and Delivery

The work of Nielsen, Goldman and Mann (2007) reports a study that evaluated “the effect of teamwork training on the occurrence of adverse outcomes and process of care in labor and delivery.” It is reported that a “cluster-randomized controlled trial was conducted at seven intervention and eight control hospitals.” (Nielsen, Goldman and Mann, 2007) The intervention is reported to have been a standardized teamwork-training curriculum “based on crew resource management that emphasized communication and team structure.” (Nielsen, Goldman and Mann, 2007) The main outcome is reported as having been “the proportion of deliveries at 20 weeks or more of gestation in which one or more adverse maternal or neonatal outcomes, or both, occurred.” (Nielsen, Goldman and Mann, 2007) Additional outcomes are stated to include “11 clinical process measures.” (Nielsen, Goldman and Mann, 2007)

Results from the study report having trained 1,307 personnel and analyzing 28,536 deliveries. It is stated that at baseline “there were no differences in demographic or delivery characteristics between the groups.” (Nielsen, Goldman and Mann, 2007) The mean Adverse Outcome Index prevalence was similar in the control and intervention groups, both at baseline and after implementation of teamwork training (9.4% versus 9.0% and 7.2% versus 8.3% respectively).” (Nielsen, Goldman and Mann, 2007) The study concludes “…training, as was conducted and implemented, did not transfer to a detectable impact in this study. The Adverse Outcome index could be an important tool for comparing obstetric outcomes within, and between, institutions to help guide quality improvement.” (Nielsen, Goldman and Mann, 2007)

Developing a Better Labor and Delivery Rapid Response Team

It is reported in the work of Catanzarite, Almryde and Bombard (2007) entitled “Grand Rounds: Ob Team Stat: Developing a Better L&D Rapid Response Team” that while the majority of pregnancies proceed “smoothly with minimal obstetricintervention, serious obstetric emergencies occur in 1% to 2%. Situations that typically requireurgent, if not emergent, medical intervention include eclampsia, hypertensive crisis, diabeticketoacidosis, and severe asthma. Conditions prompting surgical intervention include acute fetaldistress, antepartum and intrapartum hemorrhage, umbilical cord prolapse, shoulder dystocia, and uterine rupture. Both medical and surgical interventions are often needed in cases ofpostpartum hemorrhage and maternal cardiac arrest. Planning for obstetric emergencies is anintegral part of the function of every obstetric service. Responses to these emergencies are ameasure of the effectiveness of an ob unit as well. They also help determine how effective the pediatric team will be in achieving optimal neonatal outcomes.” (Catanzarite, Almryde and Bombard, 2007)

ACOG Recommendations for Cesarean Deliveries

It is stated that ACOG states recommendations that surgery begin within 30 minutes of the decision for a cesarean.” (Catanzarite, Almryde and Bombard, 2007) In the case of an institution which has an “in-house obstetrician, ob anesthesiologist, and neonatal team” it is generally possible to deliver within 30 minutes using the “usual sequential activation approach.” (Catanzarite, Almryde and Bombard, 2007) This response is reported to be potentially “inadequate to prevent adverse outcomes for some types of emergencies.” (Catanzarite, Almryde and Bombard, 2007) It is reported that when “….fetal distress is due to acute uterine rupture and/or lacerated vasa previa, for instance, delivery must be accomplished as rapidly as possible, preferably within a few minutes. Adverse perinata outcomes may occur even when the baby is delivered well within 30 minutes of the event. And during maternal cardiac arrest, delivery is recommended within 4 minutes for both maternal and fetal indications.” (Catanzarite, Almryde and Bombard, 2007)

It is reported that even the “30-minute ‘decision-to-incision’ goal is described as being an ‘elusive target’ with institutional series showing up to half of emergency C/S not meeting that goal.” (Catanzarite, Almryde and Bombard, 2007) Decision-to-incision times among 3,080 C/S performed for emergency indications at 13 university medical centers of the Maternal-Fetal Medicine Units Network report that 17% of these began within 10 minutes of decision, 44% began within 20 minutes and 62% began within 30 minutes. (Catanzarite, Almryde and Bombard, 2007)

An analysis of the time to delivery in cases of “unexpected profound fetal bradycardia” showed that nursing interventions required from between three and ten minutes. Reaching the physician by phone required between three and five minutes and a response took between ten and fifteen minutes. Even in the case where the obstetrician is at the hospital, it is stated to be “unlikely that the patient and anesthesiologist will be in the OR within 10 minutes of the onset of fetal bradycardia.” (Catanzarite, Almryde and Bombard, 2007)

The work of de Regt, et al (2009) entitled “Time From Decision to Incision For Cesarean Deliveries at a Community Hospital” reports the implementation of a quality improvement program at a tertiary public hospital with 4,500 deliveries each year through use of a hypothesis that stated “there would be differences in efficiency based on indication for cesarean delivery and using a 30-minute standard as a measure. The study identified contributors to delays and examined surgical suite use including the availability of:

(1) operating room scrub team;

(2) anesthesiologist;

(3) surgeon; and

(4) physical operating room space. (de Regt, et al, 2009)

It is reported that a quality improvement initiative was created “based on the identified needs” and the PDCA (plan-do-check-act) model of improvement was used which involves the development of a plan, initiation of the plan, assessment of the plan and followed by interventions. The report states that the hospital was “able to demonstrate an improvement in nonscheduled cesarean delivery efficiency using percent operating within a 30-minute window over a 3-year period.

A collaborative multidisciplinary approach was taken, with frequent feedback as specific causes of delays were found. Initially, reasons for case delays were availability of another complete operating room scrub team, anesthesiologist, and operating room.” (de Regt, et al, 2009) It is reported that as contributors to delays were analyzed “it quickly became clear that were harder to duplicate than the equipment and operating room space necessary to run another room. The data clearly showed nursing and anesthesiologist availability were limiting.” (de Regt, et al, 2009) Upon having identified the times of day with the most frequent cesarean deliveries that were emergencies it is reported that the hospital “…consolidated the OR blocks for scheduled cases to maximize staff coverage. Use of a separate operating room for scheduled cases minimized the occurrence of nonscheduled cases preempting scheduled cases, leading to a more consistent operation of staffing and case prioritization. Use of a patient instruction sheet about the cesarean process helped reduce patient-related delays.” (de Regt, et al, 2009)

The hospital reports it was most effective in bringing about change “when delays were examined constructively and collaboratively with the ultimate goal of helping patients and their families, providers, and nursing staff to provide safe and efficient care.” (de Regt, et al, 2009) It is stated that quality improvement projects that have their focus on the efficiency of surgery and times that surgery begins are reliant upon a multidisciplinary approach. It is reported that the work of Funai et al reported the use of “improved communication and oversight for reduction of a composite of obstetric adverse events.” (de Regt, et al, 2009)

Recommendations of the American College of Obstetricians and the American Society of Anesthesiologists

It is suggested by the American College of Obstetricians in a joint publication with the American Society of Anesthesiologist that a “goal of availability of anesthesia and surgical personnel to permit the start of a cesarean delivery within 30 minutes of the decision to perform the procedure.” (de Regt, et al, 2009) The hospital in this report states that they realized successful reduction of decision-to-incision times through implementation of various collaborative innovations. (de Regt, et al, 2009, paraphrased)

Reducing times in cesarean delivery decision-to-incision times is reported to be other than a one-size-fits all procedure and states that improvements are:

(1) dependent upon the situation on the basis of indication and urgency;

(2) dependent on availability of staff;

(3) dependent on the facility operating room availability;

(4) dependent on scheduling; and

(5) dependent on preparedness of patients to accept the procedure. (de Regt, et al, 2009)

Successful projects are stated to make a requirement of “examination of barriers to efficient running of obstetric units not only to maintain excellent outcomes but also to conserve precious hospital resources and staff time.” (de Regt, et al, 2009)

CRM – Leonard, Graham and Bonacum (2004)

The work of Leonard, Graham and Bonacum (2004) entitled “The Human Factor: The Critical Importance of Effective Teamwork and Communication in Providing Safe Care” reports that the development and implementation of crew resources management (CRM) in aviation “offers valuable lessons for medical care.” Leonard, Graham and Bonacum (2004) report “to the inevitable barriers. Our experience has reinforced the belief that simple rules are best for managing complex environments.” The most valuable of all “tools and concepts according to Leonard, Graham, and Bonacum (2004) are those which are “…collectively known as SBAR (situation, background, assessment, recommendation): a situational briefing model, appropriate assertion, critical language, and awareness and education regarding the fact that nurses, physicians, and other clinicians are taught to communicate in very different styles.” Communication failures are reported to be the “leading cause of inadvertent patient harm.” (Leonard, Graham and Bonacum, 2004)

The Joint Commission for Hospital Accreditation reveals that when analyzing 2455 sentinel events “the primary root cause in over 70% was communication failure. Reflecting the seriousness of these occurrences, approximately 75% of these patients died.” (Leonard, Graham and Bonacum, 2004) Many factors are reported to contribute to communication failures including the fact that nurses and doctors are trained to communicate very differently in that nurses are taught to be very broad and narrative in their descriptions of clinical situations while physicians are very concise.

It is reported that SBAR is effective “in bridging this difference in communication styles and helping everyone get in the same movie.” (Leonard, Graham and Bonacum, 2004) SBAR is reported to stand for:

(1) Situation;

(2) Background;

(3) Assessment; and

(4) Recommendation. (Leonard, Graham and Bonacum, 2004) This allows for critically important information pieces to be transmitted in a standardized manner which is predictably structured. It is stated that “teaching people how to speak up and creating the dynamic where they will express their concerns is a key factor in safety.” (Leonard, Graham and Bonacum, 2004) It is reported that many times the lack of a “common mental model or hierarchy gets in the way.” (Leonard, Graham and Bonacum, 2004)

Summary and Conclusion

This study has examined an extensive base of literature relating to cesarean deliveries and has identified several methods that can be used by the multidisciplinary hospital team in the process of cesarean deliveries to ensure the safety of the patient and the unborn child. While these methods are all similar, the one key factor that these studies have in common with one another is the need for effective communication between members of the labor and delivery team.

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